ICE REVIEW FOR COMP!!

1. Defense Mechanisms a. Denial- avoid thinking about external reality in favor of internal reality b. Displacement- kick the dog c. Humor- laugh it off d. Intellectualization- learn about it e. Projection- disowning unwanted thoughts and attributing them to another personsexual/aggressive in nature f. Rationalization- bad teacher g. Regression- acting like a child h. Repression- forgetting something- unhealthy i. Sublimination- putting into a socially acceptable behavior j. Suppression- forgetting something for the time being- healthy k. Transference- patient to doctor l. Counter transference- doctor to patient 2. Skin lesions Macule- freckle Patch- big macule, port wine stain Petechiae- those red dots Purpura- 4-5 petechiae Ecchymosis- bruise Spider angioma- spider like, red thing Papule- raised macule, mole Plaque/Scale- psoriasis, dry skin Nodule- in dermis, basically like a hard solid thing in the skin Tumor- bigger nodule Cyst- fluid filled nodule Vesicle- blister Wheal- bug bite Bulla- big blister Erosion- wearing away of skin Ulcer- bedsore Fissure- cracked lips Bloodborne Pathogens Introduction to Ethics a. Hippocratic oath b. Sources of values i. Parents ii. Culture/Society iii. Religion iv. law Confidentiality a. Scenarios b. Why keep confidential i. Privacy ii. Social status iii. Economic advantage iv. Open communication v. Seeking help

2. 3.

4.

vi. Trust vii. Promotes autonomy c. Disclosure- competing values i. Violent wound report ii. Suspicion of abuse or neglect iii. Danger to self or others iv. Communicable disease 5. Informed Consent a. Capacity- age, maturity, cognition, considered choice, consistent, communication b. Reasonable provider and patient c. Types of consent i. Implied- they are there with gown, not saying no ii. Presumed- unable to speak, do whats best- emergency room principle iii. Waived- patient tells dr to make decisions iv. Proxy- someone else speaks for patient v. Therapeutic privilege- withhold information from patient in their best interest 6. Medical Professionalism- be professional!!! a. Empower patient, help them make informed decisions 7. Structure and function of the interview a. Gain lots of info in the interview! b. Patient satisfaction important c. UCLA- pediatrics d. Canadian- headaches e. 3 basic functions of med interview i. build relationship with px ii. gather clinical data iii. px education and motivation f. PEARLS- partnership, empathy, apology, respect, legitimization, support g. Empathy not same as sympathy h. Open ended questions, let px do the talking, open closed question cone i. Set agenda in first 2 min! j. Anything else question 8. Patient Centered Clinical Method a. Biopsychosocial model b. Disease vs illness i. Disease= the pathology ii. Illness=the experience 9. Stress, Illness and Health a. UCLA melanoma study- having support helps the patient b. Stress= PATIENT PERCEPTION! c. Learned helplessness- cold, cruel world d. Type A personality disorder=DELANEY AND VILJOEN!!! Ultra competitive e. Learned hopefulness- glass half full f. Coping with stress- relaxation and meditation, biofeedback, etc 10. Patient Education a. Compliance- yield to desire, command, cohersion, etc

b. Participation- partnership c. Adherence- agree to join, participate willingly d. Adult learner- self motivated, experienced, problem centered, set goals and practice, want
positive env e. Health belief model- seriousness, susceptibility, solution f. Pitfalls- time restraint, jargon, assumptions, dr and nurse say different things Introduction to human dvpt and behavior a. Freud- psychosexual i. Stages of dvpt 1. Oral- sucking, biting 2. Anal- potty training, bowels 3. Phallic- only in males, come to terms with same sex parent 4. Latent 5. Genital- mutual gratifying relationships with others ii. Structure of mind- ego (conscience), superego (angel), id (devil) b. Erikson- psychosocial -Trust vs mistrust- developing trust in mother to provide for you -Autonomy vs doubt- child ventures on his/her own: more autonomous -Initiative vs guilt- interaction with peers: fit in with society -Industry vs inferiority- how you perform; will you be inferior? -Identity vs role confusion- who am i? why am I here? Jr high/high school -Intimacy vs isolation- forming intimate relationship with someone else -Generativity vs stagnation- worried about others, giving back: become mentor -Ego integrity vs despair- older, not as active, not needed as much in society: why still here? Look back on life to see if you made a difference c. Piaget- adds children Sensory motor- birth to 3 yo- learn based on senses Preoperational- 3-6 yo- use representations for objects Concrete operational- 6-11 yo- view world from own perspective Formal operations- 12+- abstract thought possible- some never get to this stage d. classical vs operant conditioning Childhood Growth and Development a. Social smiling- 2 months Adolescent Growth and Development a. Tanner Stages b. Interviewing i. Establish rapport ii. Assess devpt, address confidentiality iii. Speak plainly, sep from parents iv. Involve patient, include parent v. Ensure followup vi. Reassure c. Assessing risky behavior i. Home ii. Education, employment iii. Activities iv. Drugs, depression, diet v. Sexuality and Safety

11.

12. 13.

d. Mature minor 14. Adult Development a. Stages, transitions and rights of passage b. Erikson- Life Span Model- each life stage characterized by task to be resolved. Degree
of success in each stage is dependent on success of previous stage. Not everyone passes all stages and attains integration c. Levensen- Life Stage model- early adulthood, middle adulthood, late adulthood. As you get older, you have new demands that you have to deal with individually d. Neugarten- Social Clock theory- cultures define age boundaries and age appropriate behavior ie when you drive, marry, etc e. Gilligan- womens dvpt, more tuned to relationships, more caring, weigh decisions based on how they affect relationships and not right or wrong f. Age 30 crisis- who you are vs what you do 15. Death Dying and Grief a. Kubler Ross- Denial, Anger, Bargaining, Depression, Acceptance b. Weisman- Existential plight, mitigation and accommodation, decline and deterioration and preterminality and terminality 16. Depression a. SIGECAPS- sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal thoughts b. Adjustment disorder- onset within 3 mo of identifiable stressor and resolution within 6 mo c. Dysthimia- low grade depression for more than 2 years, poor prognosis d. Seasonal affective disorder- onset of depressive symptoms, eat a lot and sleep a lot, fall and winter, treatment is light therapy e. Bipolar I- manic and major depression f. Bipolar II- hypomania and major depression g. Cyclothymia- mild depression and hypomania h. Post partum blues vs depression vs psychosis i. Bipolar- 3 or more of the following i. Flight of ideas ii. Racing thoughts iii. Distractable iv. Psychomotor agitation v. Excessive involvement in risky pleasurable activities vi. TREAT WITH LITHIUM Uncertainty in Clinical Medicine Objectives Understand the concept of irreducible uncertainty -Irreducible uncertainty is uncertainty that cannot be reduced by any activity at the moment action is required. -lack of time to gather more information about the patient or to search medical literature adds to inherent uncertainty -basically you dont have enough time or resources available to no EVERYTHING you need to know about a patient. There will always be some uncertainty Understand the difference btwn process and outcome -PROCESS= coherence, the basic science approach, pick the world apart to see how it works -Process Approach

-Strategy- use the scientific method to increase our knowledge base -Methods- generate hypotheses, do experiments, analyze result, draw conclusions -Goal- increase understanding of how the system works -basically study the microorganisms that would be causing a disease in order to diagnose -OUTCOME=correspondence, the probabilistic approach, can we get it right without knowing the system, dont care what the cause of a problem is -Outcomes Approach -Strategy- uses epidemiological (probabilistic, actuarial) methods to predict outcomes -Methods- collect frequency data and relate outcomes to potential predictor variables -Goal- develop more accurate methods of predicting outcomes of interest -basically study the signs and symptoms of an illness to figure out the diagnosis *these are not mutually exclusive Define core concepts of epidemiology including o Prevalence- frequency of a disease o Incidenceo Sensitivity- the proportion of patients with disease who have the clinical indicator for the disease o Specificity- the proportion of patients without disease who do not have the clinical indicator o Predictive value positive- probability of a disease when indicator is positive o Predictive value negative- probability of a disease when indicator is negative Recognize the ways physicians and patients deal with uncertainty o Physicians vary in their approach Ignore/deny uncertainty you have a viral illness you need an angiogram explicit discussion of uncertainty the surgical repair is successful in 9 out of 10 patients but medical management is also an option we dont know the cause of your fainting spells, but patients with your type of problem have a normal life expectancy o Physician strategies in the face of uncertainty Time is important, often clarifies the situation Order more tests Consult with ppl that know more than you o Patients need to realize that doctors dont know everything and that they will do their best to help them figure out what is wrong. But they must be willing to deal with uncertainty Discuss an approach to the diagnosis and management of up to 3 common problems in primary care involving uncertainty Using case examples, discuss the application of decision rules, practice guidelines and/or epidemiological principles as strategies for decision making in the face of uncertainty

Sexual Function Objectives List up to 5 reasons why sexual histories are important in the care of patients

Risk of STDs, unwanted pregnancy Impact of medical illness/treatments on sexual functioning and sexual health Past sexual history may be essential to understanding current problem Knowledge of sexual orientation is important providing effective and sensitive care Concerns about sexual well being are prevalent, but patients are often reluctant to initiate discussion of these problems Describe the phases of the sexual response cycle and the physical changes in men and women associated with these phases o Appetitive (desire) phase- marked by sexual fantasies, desire for sexual activity o Excitement (arousal) phase- marked by a subjective sense of sexual pleasure. Physical markers in men include erection. In women markers include vaginal lubrication, swelling of external genitalia. Extended period of excitement during sexual activity is also referred to as plateau phase o Orgasmic (peak) phase- marked by release of sexual tension and rhythmic contraction of perineal and pelvic reproductive organs o Resolution- marked by subjective sense of relaxation. Men enter a refractory period of variable length in which they are incapable of erection and ejaculation. However, women can respond to additional stimulation almost immediately Describe the types of sexual dysfunctions associated with different phases of the sexual response cycle in both men and women o Appetitive/desire disorders Hypoactive sexual desire disorder- deficient or absent sexual desires, fantasies (occurs in up to 50% of females and 25% of males) Sexual aversion disorders- extreme aversion to and avoidance of genital contact with a partner o Sexual arousal disorders Female arousal disorder- failure to attain or maintain the lubrication/swelling response until the completion of the sexual activity and/or a lack of the subjective sense of pleasure associated with the arousal and plateau stages Male erectile disorders- failure to attain or maintain erection until the completion of sexual activity and/or lack of subjective sense of pleasure o Orgasmic disorders Inhibited male and female orgasm- delayed or absent orgasm following normal sexual excitement phase Premature ejaculation o Sexual pain disorder associated with excitement and/or orgasmic phases of the response cycle Vaginismus- involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual activity Dyspareunia- genital pain in either gender before, during or following intercourse that is not caused by lack of adequate lubrication or vaginismus Identify medical conditions and treatments that can affect sexual functioning o Medical conditions CV- atherosclerosis, thrombosis, aneurysm, cardiac failure Endocrine- pituitary problems, adrenal problems, thyroid problems, gonadal dysfunction, diabetes, etc Genetic- Klinefelters, structural anomalies, Noonans Hematologic- anemia, leukemia, immunologic, sickle cell Hepatic- cirrhosis (alcoholic) Infectious- urethritis, prostatitis, TB, gonorrhea, etc

o o o o o

 Neurologic- MS, Parkinsons, stroke, CNS tumors, CNS infections, trauma,

epilepsy, spina bifida, cerebral palsy, etc Nutritional- malnutrition, vitamin deficiency, morbid obesity Poisoning- lead Pulmonary- respiratory failure Renal/Urologic- chronic renal failure, urethral structure, etc Surgical- prostatectomy, renal biopsy, bypass, etc Traumatic- pelvic fracture, urethral rupture, penectomy Other problems- radiation therapy, any severe systemic problem o Treatments Antianxiety medication Anticholinergic Anticonvulsant Antidepressants Antihypertensives Antihistamines Antipsychotic meds Narcotics Define the sexual history and list all component parts of a comprehensive sexual history o Sexual history is gathering information about a patients sexual activity. This could include sexual partners, frequency of activity, sexual orientation, etc o Components Marital/partnership status Current sexual activity (past as well) Sexual orientation Type of sexual activity # of sexual partners STD risk Functioning/satisfaction History of abuse Contraception history Male questions (erections, premature ejaculation, etc) Female questions (lubrication, pain, orgasm, etc) Be able to articulate circumstances in which sexual histories should be pursued o When pertinent to patients CC for reason of visit (contraception ?s, reproductive concerns, UG symptoms, concerns about STDs,etc) o To assess patients risk for STDs o When the patient is concerned about sexual health List 2 places in the general medical history where questions about sexual functioning could be asked o Social history o UG review of systems o HPI Provide at least 2 examples of transition statements for introducing the sexual history o An area of health physicians often neglect is sexual health. I make it practice to let all my patients know that I am available to discuss any ?s or concerns you may have. Do you have anything you would like to discuss?

o I am going to ask you a few questions about your sexual history. These are ?s I ask all
patients, and you dont need to answer anything that makes you feel uncomfortable. If you wonder why I ask any specific questions, let me know. o Many ppl are worried about AIDS and other STDs. Do you have any questions or concerns about your own risk for these problems? Identify barriers to conducting sexual histories and describe up to 5 techniques for overcoming barriers to sexual history taking o Barriers Discomfort with subject Worry patient will be offended Not knowing how Age difference Lack of justification Stigma Perceived as irrelevant o Overcoming Barriers Delay sensitive questions Develop rapport Display nonjudgmental attitude Provide explanation for why you are asking these questions Discuss patients feelings about this topic Provide optimism Dont assume! List risk factors associated with STDs o If you are having sex you basically are at risk for an STD bc all men have diseases! o Know NE statues that apply to STDs and contraceptive counseling to underage patients If the patient is a mature minor, you can offer STD and contraceptive counseling to underage without contacting their parents mature minor is at discretion of the physician List currently available forms of contraception and know the advantages and disadvantages associated with each method. Given a clinical scenario, be able to make a recommendation that fits the scenario and the rationale behind your recommendation o Abstinence Advantages Very effective No technology required Reduced STD rates Disadvantages Failure rate Hard to teach

o NFP- effectiveness- 0, typical- 25 Advantages No technology required Disadvantages Failure rate Requires knowledge, education, planning, motivation

o Withdrawl- effectiveness- 4, typical 19 Advantages Cheap Available Disadvantages High failure rate Requires high level of trust in partner o Male condom- effectiveness- 3, typical-14 Advantages Inexpensive STD prevention Disadvantages Decreased sensation Planning required Interrupt sexual activity Shelf life o Spermicidal Contraceptives- effectiveness typical 5-12 Advantages Cheap and available Disadvantages Requires planning Interrupts sexual activity Irritation Using >1 time a day may increase risk after HIV exposure o Female Condom- effectiveness- theoretical 5, typical- 21 Advantages No cooperation from male partner Can be inserted hours in advance Does not have to be removed immediately after intercourse Relatively inexpensive STD protection Disadvantages Less effective than male condom Less widely available Slightly more expensive than male condoms 25% unable to insert properly on first attempt o Vaginal sponge- effectiveness: typical nulliparous- 18, parous- 28 Advantages Limited STD protection No doctor visit required Disadvantages Some experience vaginal dryness/irritation Some find it hard to insert o Diaphragm- effectiveness: theoretic-6, typical- 20 Advantages No interference with normal physiology

Limited STD protection Disadvantages Requires planning Requires fitting Increased UTIs Cervical Cap- effectiveness: nulliparous- theoretic- 9, typical- 20, parous- theoretic- 26, typical- 40 Advantages Same as diaphragm Less UTI risk than diaphragm Disadvantages Same as diaphragm Higher rate of failure than diaphragm Combination Oral Contraceptives- effectiveness: theoretic- .1, typical- 5 Include seasonale, mini pill, depo-provera (shot), implantable (Norplant), Lunelle, Othro evra (patch), nuva ring (insert ring into vagina), IUD Paraguard T, IUD Merina Advantages Effectiveness Availability Periods more regular/less dysmenorrheal Increased bone density Less endometrial and ovarian cancer Disadvantages Thromboembolic disease CVA Hypertension MI Depression Nausea.vomiting Wt gain Menstrual irregularities melasma Sterilization Tubal Ligation- effectivness- .4% Advantages- permanent Disadvantageso Permanent o Requires general anesthetic o Requires opening the abdomen Essure- effectiveness- .2% (block tubes with insert) Advantages o Permanent o No general anesthetic o No incision o Takes ~35 min to do Disadvantages

 Male sterilization Effectiveness- theoretic- .1, typical- .15 Advantages o Permanent o Effective o Less invasive than tubal ligation Disadvantages o Permanent, but not immediate o Surgical procedure o Questionable associated with prostate cancer o Morning after pill OCP, Preven, Plan B, RU-486 o Abortion Chemical Surgical

o Permanent o 3-6 mo delay in effect o requires hysterosalpingogram for confirmation

Discuss strategies for preventing spread of HIV and other STDs o Safe sex- contraception, barriers o Open communication of partners o Abstinence Discuss the emotional and behavioral consequences of HIV and other STDs Explore your own attitudes and feelings about sexual behavior Who Pays the Bill? 1.) Define and briefly discuss indemnity insurance, health maintenance organizations (HMO), preferred provider organization (PPO), point of service plan (POS), capitation. PhysicianHospital Organization (PHO), quality, gatekeeper, value, Medicare, Medicaid, Champus, and fee for service. a. Indemnity insuranceyou pay now, they cover your ass later. They offer cash payments for health services regardless of the expenses actually incurred. Pay little.they pay a shitload. Sounds like good insurance, where can I get me some of this? b. HMOrepresent the most dynamically developing segment of the US health care system. HMOs provide managed health carethe integration of the financing and delivery of are. Typically, HMOs contract w/ employers to provide comprehensive health services for their employees in exchange for a monthly fee. HMOs have a strong financial interest in controlling the cost of care while maintaining and improving quality. Here you have to use clinicians of the planphysicians are enticed to participate and in return the HMOs really take over and determine the cost. c. PPOThese are loosely controlled versions of managed health care. They often play a broker role between employers and providers. Participating physicians are asked to provide services for negotiated discounted prices in order to preserve or increase their market share. So here physicians may be making their patients pay less but they will be getting more of them b/c of the low priceseverything balances out often in favor of physicians. PPOs are also characterized by consumer choice of providers, utilization review, and expedient settlement of claims. i. Often needed, are preauthorization for admission to hospital or mandatory second opinions on elective surgeries. d. POSthese also offer reimbursement for the services of out of network physicians but at a lower rate. Currently nearly 80% of HMO enrollees are offered point of service option.

e. f. g.

h. i. j.

k. l. m.

So basically POS protects choice. If you are insured by an HMO and you go to a doctor out of the network, then a POS can offer payment for some of your services. CapitationYou pay monthly regardless of the amt. of healthcare or shitty health care for that matter that you get. Fucking HMOs.bastardsBoo those whores. Physician-Hospital organization Quality i. Quality of designex appropriateness of surgical procedure to treat a particular medical condition ii. Quality of deliveryhow good of a doctor are you? iii. Quality of structureattempts to measure and influence the quality of care by testing and approving specific resources of carehuman resources, facilities, drugs and equipment, iv. Quality of processactivities of clinicians and assumes that there is a causal relationship between specific clinical procedures and the outcome of care v. Quality of outcomeprobably the most attractive quality concept, b/c it attempts to assess the real result of health servicesex, the change in the heatlh status of patient or populations Gatekeeper Value Medicarepersons 65 and older, disabled individuals, and patients w/chronic renal failure are entitled to benefits of medicare i. Part Afinances hospital visits ii. Part Bprovides supplementary medical insurance covering physician services, physician ordered supplies and services, and various outpt. Services. iii. Financed through payroll tax, which beneficiaries of the Part B plan paying a monthly premium iv. There are also deductibles, and other out of pocket expenses. Medicaidfinances health care provided to low income individuals and families i. Income is being redistributed from the rich to the poor through this (MY ASS!) ii. Welfare medicine Champus Fee for service

Demonstrate understanding of billing formats for services rendered based on o HCFA-1506 o ICD9 codes- international classification of diseases clinical modification (ICDCM) official system of assigning codes to medical and surgical diagnoses and procedures >12000 diagnoses codes format is 123.45 o CPT- current procedural terminology Uniform language describing medical, surgical and diagnostic services 2 extra digits much more specific procedure codes mostly format is 12345 (-67) Define insurance coverage items and given a scenario describing services covered for patients with different insurance plans, be able to calculate the amts paid by insurance plan and patient respectively

o UCR- usual, customary and reasonable charge- reimbursement determined by the

insurance company and purported to reflect the common or prevailing fee for a specific health service in a defined geographic area (may vary among insurance companies) o Deductible- the portion of allowable health care expenses which an insured must pay before insurance coverage applies: usually expressed as a dollar pay before insurance coverage applies. Usually expressed as a dollar amt per calendar year. Eg $250/calender year means the insured must pay $250 of allowable health expenses before their insurance begins coverage by co-insurance o Co-insurance- division of responsibility for payment btwn insurance company and insured, expressed as a percent eg 80/20 (insurance covers 80%, insured covers 20%) Discuss at least 5 ways in which managed health care plans limit costs o Tell dr how much they can charge for a certain procedure o Limit amt of care that patients can be given o Limit defensive medicine o Limit the lengths of hospital visits, etc so that costs cannot be increased too high o Use gatekeepers- in order for insurance to pay, you must have referral of primary care doc to specialist o Drs must pay HMO if they go above and beyond what the HMO will pay Discuss the ethical dilemmas in which managed care plans place physicians o The physician is basically a bitch employee of the HMO so the HMO can basically be like, umm bitch, no you cant do that about anything that the physician wants to do (boo those whores to HMOs). The physician thus is placed in quite the predicament: either keep my low paying HMO shitty ass job, or do what is best for the patient (which may require more money than the HMO is willing to offer to the patient). The physician doesnt have much money obviously bc he is being paid by fucking HMO, but he must decide if it is worth it to pay out of pocket to help his patient or if he should bow down to the gods of the HMO and not give the patient what is needed. Describe the ways managed care plans may preserve the physicians role and limit ethical conflicts with their patients o The physicians role is preserved in that he/she is still acting as a healer. The physician still sees patients and is able to give diagnoses and treatment. However, the role is limited bc the physician cannot give a number of the treatments, screens, etc that he/she may deem necessary. The HMO will get mad at the physician if he/she spends too much of their precious money and if the physician goes over this amt then they have to pay out of their own pocket for the things that they think may be necessary to help a patient o Ethical conflicts are limited bc basically the physician doesnt have the ability to offer many options to the patient. The patient therefore can most likely not pick something that is experimental, etc due to the HMO and will probably just pick the most basic of treatments that is covered by their HMO. So, limiting the amt of choice that the physician and patient have will limit the amt of argument that comes between them

Medical Records

1.) Know the basics of SOAP notes and POMR a. SOAP notes i. S= SubjectiveWhat the patient tells you. ii. O= ObjectiveData, exam, tests, etc. iii. A= AssessmentDiagnosis iv. P=Planwhat youre going to do b. POMR i. Problem Oriented Medical Record

ii. This is the master problem list iii. All records refer back to this master problem list 2.) List the major categories to be covered in hospital orders. a. Discharge Summary i. Admitting diagnosis ii. Discharge diagnosis iii. Reason for Admission iv. Hospital course v. Lab and x-ray results vi. Plan of follow up vii. Condition on discharge viii. Discharge instructions b. Admitting Orders i. ADCA 1. A= Admission order, location 2. D= Diagnosis 3. C= Condition 4. A= Allergies ii. VAN 1. V= Vital Signs 2. A= Activity 3. N= Nursing orders a. Weight b. Intake and Output c. Check glucose, etc. iii. DIMLS 1. D= Diet 2. I= IV orders 3. M= Medication orders 4. L= Lab and x-ray studies 5. S= Special orders a. Other services b. Respiratory 3.) List the Major Categories of a Prescription a. Definition of prescription i. Patient name ii. Datesix months past date and the prescription can no longer be fulfilled iii. Medication iv. Quantity v. Dose vi. Type vii. Strength viii. Route ix. Frequency x. Length of treatment xi. Indication

xii. Refills xiii. DEA number xiv. Physician signature (make sure to print name) xv. Generic status xvi. Special Instructions 4.) Be able to list the pertinent legal standards for medical student participation in medical records a. Any medical document can become a legal document b. Best defense against malpractice is good charting c. Co-signature by preceptorsif you write something in a chart, you have to have your d. e. f. g. h.
preceptor sign it too Controlled substances Erasures/corrections Students can be named in malpractice actions Malpractice insurancewe are not insured by malpractice, but our preceptors arethey take the fall for our screw HCFA regulations

Reproductive Rights (Ethics and Reproduction): A Panel Discussion

1.) Know the relevant Federal and Nebraska state laws on contraception and abortion a. To begin with, privacy is defined as a penumbral right (this means it is not explicit but b.
it is implied by other explicit rights Contraception is a private decision i. States cannot proscribe distribution or use of contraception ii. States, however, can enact safeguards 1. statutes and case law influence available options for minors a. NE law allows STD treatment and prevention of STDs w/o parental consent. Essentially here as a physician, we can diagnose, treat consenting patient for STD patient for STDs and may prescribe prophylactic treatment to prevent exposure. Consent or notification of a parent is not required for a minor. b. MDs can prescribe oral contraceptives to mature minors (defined by the discretion of the doctor) w/o parental consent c. Permanent sterilization of minor/incapacitated requires court order this is unless the sterilization was an unintended byproduct of a medically indicated treatment to begin with 2. FDA regulates product safety of all contraceptives Abortion i. Abortion is a decision of the patient and the physician but involves a BALANCE of interests by both 1. states cannot prohibit abortion pre-viability (defined as before 24 weeks) This means that states cannot prohibit abortion if the pregnancy is 0-23 weeks along. This favors the mother 2. States can limit or prohibit abortion post-viability (past 24 weeks). Here the balance shifts towards the fetus. 24 weeks is defined as the time when a fetus can live on its own w/o mother so defined as a life.. Viability is a medical decision, but the criteria may be set by the statute. 3. The entire scheme, however, can be thrown off when the life of the mother is in danger.

c.

4. States can enact safeguards throughout gestation a. The scope of state control has been the subject of 33 yrs. Of court cases 5. Nebraskas current statutes regulating abortion a. Preamble deplores the U.S. Surpreme Courts legislative intrusion.
Basically the preamble just states that NE doesnt like the decision by the supreme court to remove the protection afforded by the unborn. It says that all precautions should be taken to insure the protection of every viable unborn child and that all effort should be made to save lives of viable unborn children b. Voluntary informed consent and a 24 hour waiting period is required before the procedure. This is waived only in an emergency. Emergency also waives consent components. It is our job as MD to explain the nature of the emergency and the need for immediate action c. Consent Information given by MD, PA or RN (can be via phone or in person) and must include the following i. Medical risks of the particular procedure ii. Probable gestational age of the unborn child at the time of the procedure iii. Medical risks of carrying to term iv. Name of the MD to perform procedure (no non-MD can perform class IV felony) v. Possible availability of medical assistance for pregnancy, childbirth and neonatal care vi. Liability of father to assist in support even when volunteering to pay for abortion vii. Availability of State materials re: abortion alternatives, fetal development 1. if electing to review, must receive 24 hours before the procedure or be mailed 72 hours before viii. Woman must certify in writing that the foregoing were furnished ix. MD or agent receives copy of certification before the procedure Abortions post-viability (past 24 wks) i. Viability determined by sound medical judgment of attending physician ii. No abortions after viability except to save life or health of the mother iii. All reasonable precautions taken to preserve the life of the child 1. this is in accord w/ sound medical judgment of the attending 2. in accord w/ preservation of maternal life and health 3. if child is born alive, all reasonable steps are taken to preserve life a. in accord w/ sound medical judgment of attending b. fetus born alive defined as with breath, heartbeat, umbilical cord pulse, voluntary muscle movt. regardless of gestational age No medical facility is required to perform an abortion and cannot be sued for refusal No person is required to participate in an abortion and employment status cant be altered for refusal No sale or transfer of living abortuses for experimentationunless transportation is reqd for saving the life of the child Monthly reports to the health dept include: i. Name of MD ii. Location of facility

d.

e. f. g. h.

iii. Age of pt. (but no names recorded) iv. Type of procedure v. Complications vi. Obstetrical history vii. Stated reasons for abortion viii. State of residence ix. Length and weight of abortus, when measurable x. Whether emergency situation caused waiver of informed consent requirement
completed form signed by MD xi. This form is confidential except on court order in civil or criminal proceeding. i. Cumulative information (except the MD and facility names) on file at health dept. j. For minors under 18 y/o or woman under guardianship i. No abortion w/o 48 hrs. written notice to parent/guardian, delivered personally by MD or agent OR mailed, certified or registered mail to usual place or residence delivery deemed to be noon on the next regular delivery day ii. Judicial bypass of parental notice if judge determines: 1. Pregnant minor is mature and capable of giving informed consent 2. Abortion w/o parental notice is in the best interests a. Forms available in courthouses and clerk will assist in filing b. Proceedings confidential and no court costs are imposed c. Files sealed except on court order d. Minor may represent self or court may appoint counsel, guardian i. County pays atty fees e. decision reqd 7 days after petition filed f. minor can appeal to Nebraska Supreme Court if not timely decided g. Refusal must include written findings of fact and conclusions of law h. Expedited review by NE supreme court 7 days after appeal 3. Parental notification/judicial bypass waived under any of the following circumstances a. Immediate threat to life or health of woman b. Person entitled to notice (for example parent) has already given written authorization c. Woman alleges abuse/neglect and MD notifies authorities Childhood disordersa. ADHD- hyperactivity, cant concentrate for long periods b. Oppositional disorder- difficult children- temper tantrums, arguing, defiance, annoying people, blaming others, anger, mean, seek revenge c. Depression- same criteria as for adults d. Bipolar e. Conduct disorder- truancy, setting fires, lying, theft, can lead to antisocial disorder Genital/Rectal/Breast a. Perform bc of dysfunction, disease, part of physical exam, patient concern, prevention, breast cancer detection, STDs b. Comfort patient by acknowledging situation, emphasize importance of exam and reason for them, include chaperone, private dressing/undressing, least uncomfortable position, drape patient, warm room, instruments and hands, explain what you are doing and avoid sudden, direct contact

2.)

3.)

c. History- urinary symptoms, ab pain/masses, perineal pain/masses/lesions, sexual

functioning, GI complaints, trauma, rectal complaints, fertility, STDs, dvptal questions i. Female- menstrual history, irregular vaginal bleeding, discharge, history of dvpt, pap spears, obgyn, mammograms, breast pain/changes/lumps/discharge, self exam? Risks ii. Male- urethral discharge, testicular pain/masses, dvptal history and self exams d. Do breast exam sitting and laying down Health Care teama. Social workers- masters degree, work with patient about non-medical concerns, family concerns, abuse, finances, acts as counselor b. NP- masters degree, can work on their own or with a doctor. On their own, can manage illnesses and treat simple cases. Can also write scripts. Main focus is primary care c. PAs- dependent practitioners- 28 mo program, can perform minor surgery, diagnose w/ doctor, write scripts, but must be with a doctor- makes drs live easier d. PTs- work with patient to restore ROM, strength, etc to muscles and bones after injury e. OTs- make it easier for a patient to live day to day life after an injury/illness Family Crucible a. Family- group of people w/ blood, legal and/or emotional ties who have a shared history, degree of emotional attachment and expected future b. Lots of variations on the family structure- most common= single mother home c. Traditional family- 8% of families d. 4 functions of family i. procreation ii. support iii. socialization iv. intimacy and conflict resolution e. acute illness- easier to deal with, family rallies, not as much long term commitment f. chronic illness- permanent change that a family must deal with, can be very stressfulespecially hard to deal with is relapsing disease g. assumptions about chronic illness and family i. may be predictable points of stress during chronic illness ii. families vary in level of tolerance iii. families under stress hold to previous patterns of behavior iv. go through grief-loss process v. families play very important role in choosing therapies vi. react to particular illness behavior vii. difficulty adjusting to illness viii. adjust to changes in expectations for each other ix. perspective of illness have most influence on ability to cope h. components of psychosocial typology i. onset- acute or gradual ii. course- progressive, relapsing (most difficult) and constant iii. outcome- fatal, shortened life span, non fatal iv. degree of disability- incapacitating, non-incapacitating i. levels of interventions i. cognitive- give info about illness ii. behavioral- instruct family to go about normal lives iii. affective- look for denial, ignorance, etc

4.)

5.)

6.) integrative medicine a. acupuncture- Qi, meridians, must get everything back in order, use pins in the meridians b. massage- lots of types, used to relax, relieve stress, give energy, etc c. chiropractic- adjustments and manipulation of spinal cord in order to relieve subluxations d. homeopathy- dilute solutions of substance that in larger amts would cause the same
symptoms as the problem being treated

e. therapeutic massage- 3 inches over the patient f. rolfing- hard touch, knuckles, elbows, etc g. HERB LECTURE OF BULLSHIT i. Aromatherapy- lavender (sedative, antidepressant, antiseptic), peppermint
(antispasmodic, decongestant, stimulant), chamomile (sedative, antispasmodic, anti inflammatory, antidepressant), eucalyptus (antiseptic, anti allergy, antidepressant) ii. Acupunture- used for smoking cessation, insomnia, nausea, vomiting, IBS, pain, low risk, dont use if pregnant iii. Homeopathy- like cures like, triggers bodys healing abilities, doesnt treat symptoms, mother substance and mother tincture 1. Dilute- decreased adverse effects and increased potency 2. Shake and bang on surface- releases energy 3. Match to symptoms 4. Not interchangeable with herbal products 5. Potentially toxic iv. Echinacea- nonspecific immune stim w/ anti inflammatory, anti viral and antibacterial, dont use with autoimmune disease v. Garlic- immune enhancer, antioxidant, vasodilator, anti-inflammatory, anti diabetic, anti cancer, decreases lipids, decreases BP- odor, flatulence vi. Ginseng- antiviral, energy boost, dont use if HTN, anxiety, diabetes vii. Vitamin C- antioxidant, decreases histamine levels, suppresses bronchoconstriction, strengthens blood vessel walls, healthy gums and bones viii. Zinc- antiviral, bad taste ix. Glucosamine- osteoarthritis- stim cartilage growth, no bad side effects x. Chondrotin- osteoarthritis, protect cartilage from further breakdown xi. MSM- pain from osteoarthritis, may thin blood xii. Omega 3 FAs- anti-inflammatory, decreased chol and TG, may increase HDL and LDL, increase insulin sensitivity xiii. St Johns Wort- treats mild to moderate depression, PMS and is antiviral- can cause mania, activates CYP3A4 xiv. Chamomile- sedative, antispasmodic and anti-inflammatory xv. Kava Kava- used for stress, anxiety and restlessness xvi. Valerian- GABAnergic sedative, hyponotic xvii. Sedating herbals- lavender and lemon balm xviii. Melatonin- used to treat jet lag xix. Ginkgo biloba- circ stim, antifungal, astringent, strengths blood vessel walls, antioxidant, increases GABA and muscarinic receptors, treats Alzheimers by inhibiting deposition of b amyloid, can cause seizures and bleeding in brain xx. Green Tea- wt loss, cancer, anti oxidant, antibacterial, ulcers, increases glc utilization xxi. Soy- antioxidant, cardiac health, menopause, osteoarthritis xxii. Toxic Herbs- pyrrolzidine alkaloids, volatile oils and lignans

h. Avoid products from asia and that contain lots of herbs i. Use recommended dose j. Lots you cant take during pregnancy 7.) Faith and Medicine a. Life/body i. Hinduism- sacred, illness=karma ii. Judaism- body owned by God, must maintain your body iii. Catholic- Gods creation, but source of sin iv. Islam- Gods creation, illness is atonement for sins v. Mainline protestant- Gods creation, temporary vessel, life is gift vi. Fundamental Christians- Gods creation, source of sin, life is gift vii. Jehovahs witness- made for purpose, death results from Adams sin viii. Christian Science- one with God, material is illusion b. Blood i. Judaism- acceptable ii. Catholic- acceptable iii. Islam- acceptable iv. Mainline protestant- acceptable v. Fundamental Christians- acceptable vi. Jehovahs witness- not acceptable (can use own blood or maybe some blood
components)

c. Organ donation i. Hinduism- some fundamentalists say no ii. Judaism- acceptable iii. Catholic- acceptable and encouraged iv. Islam- acceptable v. Mainline protestant- acceptable vi. Fundamental Christians-acceptable vii. Jehovahs witness- not acceptable d. Medical procedures i. Hinduism- seek conventional medicine, families give care and support ii. Judaism- must do all necessary and available iii. Catholic- reasonable medical care is obligatory iv. Islam- modesty rules, cleanliness v. Mainline protestant- attention to autonomy vi. Fundamental Christians- preserve life vii. Jehovahs witness- most things acceptable viii. Christian Science- own nurses, God gives what you need e. Abortion i. Hinduism- dispproved except to save life of mother ii. Judaism- permitted to save life of mother or preserve health of mother, or before
40 days

iii. Catholic- never ok except to save life of mother iv. Islam- before 120 days ok, or to save life of mother v. Mainline protestant- womans right to choose vi. Fundamental Christians- only to save mothers life vii. Jehovahs witness- only to save mothers life

f. Contraception i. Hinduism- tolerated but not accepted ii. Judaism- accepted iii. Catholic- not accepted, NFP iv. Islam- accepted v. Mainline protestant- accepted vi. Fundamental Christians- accepted vii. Jehovahs witness- accepted- no sterilization viii. Christian Science- accepted g. Marriage i. Hinduism- procreation is desirable (esp sons) ii. Judaism- companionship and reproduction iii. Catholic- procreation and mutual self giving iv. Islam- procreation encouraged v. Mainline protestant- procreation honored but not obligatory vi. Fundamental Christians- procreation is expected vii. Jehovahs witness- procreation encouraged h. Reproductive technologies i. Hinduism- accepted ii. Judaism- accepted iii. Catholic- not accepted iv. Islam- accepted v. Mainline protestant- accepted vi. Fundamental Christians- depends on type, no donor or surrogacy vii. Jehovahs witness- no donor gametes or genetic counseling i. Ensoulment i. Hinduism- at conception ii. Judaism- 40 days iii. Catholic- conception iv. Islam- 120 days v. Fundamental Christians- at or near conception vi. Jehovahs witness- at conception vii. Christian Science- fetus is always perfect image of God, so conception I guess j. Dying i. Hinduism- disapprove of life support, can starve oneself ii. Judaism- dont have to prolong dying process, dont remove tubes, etc, non Jewish
cant touch body

iii. Catholic- reasonable measures to preserve life, much debate now, pain control
acceptable, last rites iv. Islam- duty to preserve life, dying person face Mecca v. Mainline protestant- reasonable measures to preserve life vi. Fundamental Christians- reasonable measures to preserve life vii. Jehovahs witness- artificial life support not encouraged viii. Christian Science- no medical intervention Funeral i. Hinduism- cremation ii. Judaism- burial

k.

iii. Catholic- burial or cremation iv. Islam- wrap in sheets and burial v. Mainline protestant- burial or cremation vi. Fundamental Christians- burial or cremation vii. Christian Science- based on family tradition l. Autopsy i. Hinduism- no ii. Judaism- no iii. Catholic- if necessary iv. Islam- no v. Mainline protestant- allowed vi. Fundamental Christians- some discourage, but no official rule vii. Jehovahs witness- allowed viii. Christian Science- normally not requested